Overview of Stroke: Etiologies, Demographics, Syndromes, And

Overview of Stroke: Etiologies, Demographics, Syndromes, and Outcomes Alex Abou-Chebl, MD, FSVIN Medical Director, Stroke Baptist Health Louisville Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company  Consulting Fees/Honoraria  The Medicines Co.

 Silk Road Medical Definitions

 Stroke - abrupt development of a focal neurological deficit due to a vascular cause associated with permanent neuronal injury  Transient ischemic attack (TIA)- same clinical syndrome as a stroke but resolves completely < 24 hours  i.e. without permanent brain injury (old definition)  With modern imaging most events >several hours duration are associated with infarction. Epidemiology- USA

 ~795,000 new or recurrent stroke per year  610,000 first attacks  185,000 recurrent attacks  2001 to 2011 relative rate of stroke death fell 35.1%  Actual number of stroke deaths declined 23.0%  In 2011 stroke caused ~1 of every 20 deaths in USA  On average,1 stroke every 40 seconds in USA  1 Stroke death every 4 minutes  There are ~ 4.5-5 million Stroke survivors  Stroke is the leading cause of adult disability in USA  15-30% of all stroke leads to permanent disability

Mozaffarian D, et al. Heart Disease and Stroke Statistics- 2015 Update. Circulation 2015;131:e29-322. Prevalence of Stroke by Age and Sex (National Health and Nutrition Examination Survey: 2009–2012).

Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322

Stroke is Heterogeneous

•Thrombi/Emboli of varying compositions Embolic

 Atrial fibrillation - most common embolic cause  Second most common cause of ischemic stroke  36% of strokes in patients >80 years old  With better EKG tele (implantable) 20-30% of cryptogenic stroke likely due to AF  Aortic atherosclerosis cause of 30% of “cryptogenic” stroke  Acute anterior wall myocardial infarction  Rare- Endocarditis, PFO, myxoma, hypercoagulable, air, fat, Large Vessel Thrombotic

 Carotid atherosclerosis- most common cause in USA  Usually in the presence of >70% stenosis but <50% stenosis can be symptomatic  Intracranial atherosclerosis in 7-10%  African/Asian>Caucasian, Women>Men, DM>Non-DM  Hypercoagulable states  Dissection Large Vessel Strokes Small Vessel Thrombotic

 Lipohyalinosis- small penetrating arteries (<2-400μm diameter)  MCA/BA Perforators -> disorganization and disruption of vessel lumen (hyaline material) -> occlusion -> ischemia -> necrosis -> “lacune”  Hypertension most important risk factor  Embolic origin <20%  Increased incidence in African-Americans  Single most common cause of stroke Typical Lacunar Strokes on MRI

Medial Medullary Stroke

Posterior Limb IC/Putaminal Stroke

Pontine Stroke Intracerebral Hemorrhage

 Hemorrhage into the substance of Brain  Cerebral hemispheres (20%), basal ganglia (40%), thalamus (20%), pons (10%) or cerebellum (10%)  Etiology  Hypertension (most common cause)  Anticoagulant therapy  Amyloid angiopathy- associated with dementia and increasing age  Vascular malformations (arteriovenous malformation), cavernous angioma, capillary, telangiectasia  Venous sinus thrombosis  Cerebral metastases  Trauma ICH on CT

Subarachnoid Hemorrhage

 Rupture of a Saccular aneurysm  Risk of hemorrhage dependent on aneurysm size and location  <10mm lowest risk 0.05%/year, cumulative  >10mm <25mm moderate risk 1%/year, cumulative  >25mm highest risk 6%/year, cumulative  Basilar tip location has highest risk of rupture (RR=13.8)  Trauma  Arteriovenous malformation  Mycotic aneurysm- post endocarditis ischemic stroke Typical Subarachnoid Hemorrhage and Saccular Aneurysm Differential Diagnosis- Stroke Imitators

 Mass lesion- Primary brain  Demyelination- Multiple carcinoma, metastases, sclerosis, acute disseminated meningioma, abscess encephalomyelitis  Subdural hematoma  Fever/infection in elderly with prior brain injury  Somatization (especially urinary tract infections)  Migraine  Transient global amnesia  Seizure  Encephalitis- Herpes simplex  Hyper/hypoglycemia type I  Cerebritis- lupus  Inherited metabolic derangements- Mitochondrial encephalopathies CLINICAL PRESENTATION

 Symptom onset  Large vessel ischemia  Embolic -> sudden/maximal at onset  Thrombotic -> symptoms maximal at onset or stuttering over minutes/hours  Small vessel ischemia -> progression over minutes or stuttering over hours/days  Intracranial hemorrhage  Intracerebral hemorrhage -> steadily progressive over minutes/hours -> nausea/vomiting ->headache  Subarachnoid hemorrhage -> headache instantaneous and maximal at onset- “thunderclap” Symptoms & Physical Findings

 Symptoms variable in type/intensity depending on vessel/brain region involved  Weakness, paralysis, or incoordination- Large Vessel or Small Vessel  Numbness or tingling- Large Vessel or Small Vessel  Visual loss (monocular- amaurosis fugax, binocular- hemianopsia)- Large Vessel  Cognitive dysfunction  Aphasia (dominant hemisphere, a disorder of language not articulation [dysarthria])- Large Vessel  Neglect (nondominant hemisphere)- Large Vessel  Ataxia, gait instability or vertigo- Large Vessel or Small Vessel Symptoms & Physical Findings -continued-

 Decreased level of consciousness- Large Vessel  Sudden headache with nausea and vomiting- Hemorrhage  Double vision- Large Vessel or Small Vessel  Agitation or confusion- Large Vessel  Memory loss- Large Vessel  Transient loss of consciousness (very rare without other neurological signs)- Large Vessel, usually vertebrobasilar  The term vertebrobasilar insufficiency is over used  95% of transient episodes of loss of consciousness are due to a cardiovascular rather than neurovascular cause Clinical Syndromes

 Lacunar  Vertebrobasilar  Pure Motor or sensory  Ataxia  Sensory-motor  Dizziness  Ataxic-hemiparesis  Crossed sensory-motor  Wallenberg’s  Large Vessel  Weber’s  Cortical Dysfunction  Bulbar  Aphasia  Oculomotor  Neglect  Hemianopsia  Hemiparesis/anesthesia  Early decrease  Hemianopsia consciousness Variability of Clinical Manifestations Dependent On

 Location of Occlusion/Thrombus  Collateral Blood Flow  Cerebrovascular Reserve  Size of Embolism  Severity of Hypoperfusion  Duration of Ischemia  Underlying Brain Substrate  Neuronal Reserve  Age  Medical Co-morbidities  Hyper/Hypoglycemia  Hyperthermia Stroke Mechanisms

 Embolism  Most common  MCA >> ACA

 Thrombosis

 Hypoperfusion

 Combination  “Impaired Washout of Emboli” National Institutes of Health Stroke Scale- NIHSS

 12 Item scale  Points are given for deficits  0= normal  42=No neurological function  Strict guidelines for interpreting and scoring  Requires (minimal) training  Video  Can be completed in 4-5 minutes by experienced examiner NIHSS

 1- Alertness, Commands,  8- Sensation Response  9- Language  2- Horizontal Gaze  10- Speech Quality  3- Visual Fields  11- Neglect  4- Facial Movement  12- Hand Strength  5- Arm Movement

 6- Leg Movement

 7- Ataxia Modified Rankin Scale (mRS) Neurological Disability Scale

 Grade Description  Grade Description  0 No symptoms at all.  4 Moderate to severe  1 No significant disability disability: unable to walk despite symptoms: able without assistance, and to carry out all usual unable to attend to own duties and activities. bodily needs without assistance.  2 Slight disability: unable to carry out all previous  5 Severe disability: bedridden, activities but able to look incontinent, and requiring after own affairs without constant nursing care and assistance. attention.  3 Moderate disability:  6 Death requiring some help, but able to walk without assistance.